If a seizure occurs in a newborn who suffered an intracranial hemorrhage, the nurse should record: (Select all that apply.)
a. Parts of the body and limbs that were involved
b. Witnesses to the seizure
c. Whether movements were unilateral or bilateral
d. Severity of the seizure
e. Length of time of the seizure
A, C, D, E
The nursing assessments of a seizure should include the parts of the body that were involved, whether the seizure activity was on only one side or both sides, the severity of the seizure, and the length of the seizure.
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What is the usual cause of the autoimmune disease of acute glomerulonephritis?
a. Frequent cystitis b. Streptococcal infection c. Childhood disease of mumps d. Recent wound infection
The patient comes to the diabetes clinic and confides to the nurse that she does not follow the diet exchange program that she was given. You respond:
1. "The exchange program is a carefully developed and very important program that allows you to take control of your disease." 2. "A lot of people have trouble with that program. You aren't the first one to go off your diet." 3. "We had better go ahead and check your blood work to see what you've done to yourself." 4. "Okay. Let's talk about what you do eat and drink and how you manage your diabetes."
Clients with head injuries should be placed in which of these positions?
a. dorsal recumbent c. semi-Fowler's b. prone d. side-lying
The labor and delivery nurse is caring for a client whose labor is being induced due to fetal death in utero at 35 weeks' gestation. In planning intrapartum care for this client, which nursing diagnosis is most likely to be applied?
1. Powerlessness 2. Urinary Elimination, Impaired 3. Coping: Family, Readiness for Enhanced 4. Skin Integrity, Impaired